15.5.13

THE PROTECTORS

Child Abuse Cases Arrive in the Pediatric Emergency Department with Heartbreaking Frequency. Meet the Medical Team that's First on the Scene...by Mat Edelson

THE PRE-SCHOOLER bouncing around Exam Room 3 of the pediatric emergency
room is that iridescent combination of precociousness and politeness uniquely the domain of garrulous 4-year-old girls. “I need to
wash my hands,” announces the child, gently
peeling a pink butterfly sticker off her tiny
right hand. Moments later, washed and dried with two towels (“Two at a time!” she squeals), her beaded,
neat cornrows disappear under a window shade. “Look!” exclaims the slightly muffled voice, whose owner is now staring
up into the dusk. “The Moon! It looks just like a cookie!”

The observers in the room laugh, but the girl’s mom is not
among the smiling. In fact, mom’s not even in the room. She’s
50 feet away, on the other side of electronically secured double
doors that she could not breach if she wanted to—and she
most certainly does. For while she is known to the little girl as
“Momma,” to the two security guards, one police officer, two
social workers, crime lab photographer, nurse practitioner and
pediatrician who stand between her and her baby, the woman
now wears a far more ominous moniker:

Alleged abuser.

The allegation is as plain as the inch-long rainbow-colored
bruise under the child’s right eye. It was noticed by her teacher
earlier in the day, reported to authorities as the law requires,
and the child was quickly brought down to Hopkins to have
her injury evaluated. And therein lies the question. For while
the injury is blazingly apparent, its cause is not. Accident or
abuse? The former, claims the mother, who says she wasn’t
even present when the child, at her grandmother’s, tripped
and fell face-first into the edge of a coffee table.

Which is exactly the tale the child tells to the specially
trained social worker in Exam Room 3, before adding seven
words full of both innocence and damnation:

“That’s what they told me to say.”
The social worker takes a deep breath.
“OK, now tell me what really happened.”

**** SORTING FACT FROM FICTION and making an informed recommendation is what the Johns Hopkins Child
Protection Team headed by Allen Walker is all about. The
CPT is first on the scene in the Hopkins pediatric ED, which,
by city order, is where Baltimore City police bring all suspected cases of physical child abuse for initial evaluation.

That alone is a daunting responsibility. According to the
Baltimore City Data Collaborative, from 2000 to 2005, the
city’s rate of child abuse and neglect ran almost three times
higher than the state’s average. For 2005, that meant 11.3 per 1,000 city kids had suffered everything from malnutrition to beating, burnings, and other horrific injuries at the hands of
adults. In that same year, more than 30 of each 1,000 city children were removed from their homes by social workers, the
vast majority because of suspected neglect or abuse. For children ages 6 to 11, homicide was the third leading cause of
death between July, 2001 and May, 2005: For those under 6, it
was the second leading cause of death.

A few of the more heinous cases are etched in memory. Two-year-old Bryanna Harris, whose drug-using mother, annoyed by
the little girl’s crying, purportedly gave her methadone to hush
her up. It killed the toddler. Then there was the case of
Emmoney and Emmonea Broadway, the twins delivered at
Hopkins, who were found beaten to death a month later.

The fact that city social workers were aware that the mothers in both cases were at high risk for being child abusers isn’t
lost on Allen Walker. Throughout the physician’s 30-year career in pediatrics, he’s sought better methods for identifying
potential abusers and preventing child abuse.

The soft-spoken Walker practiced in Reno before coming
to Hopkins in 1985. For years he’s fought the prevailing
American sentiment that how a parent raises a child is not
any outside agency’s business, a mindset that he says only furthers the cycle of child abuse by limiting educational opportunities. “You look at some of the Scandinavian countries,
mothers get a year off after they deliver to bond with their
kids. They get a regular home visitor who teaches them about
being a parent,” says Walker. “I don’t think anybody in the
United States would seriously think we have either the political will or financial means to do that. Yet that’s the sort of effort that, at least from the medical literature, it’s going to take
to prevent this.”

Walker has led the Child Protection Team since its inception here in the 1990s. The concept, he says, is straightforward: “to present a unified voice” of multi-disciplinary expertise. Suspected child abuse cases are fast-tracked through the
pediatric ED, where they’re thoroughly evaluated over several
hours by a phalanx of expert social workers, nurse practitioners, and physicians. The resulting reports are immediately
passed on to the police and city child protective service authorities—all in an effort to keep children safe and potential
abusers from slipping through the cracks.

Prior to the team’s formation, “It was almost impossible to
prosecute a physical child abuse case in the city of Baltimore,”
says Julie A. Drake, chief of Baltimore City’s Felony Family
Violence Division. The reason? While city and state detectives, child protective service workers, and Hopkins’ own
physicians often had information that could help determine whether abuse had occurred (or, as importantly, did not), that
information often was not shared with the right people or in a
timely manner.

Now, a formal agreement between CPT, Drake’s office, the
Baltimore City Police Department’s Child-Abuse Unit, and
the Department of Child Protective Services has led to more
successful prosecutions and cleared cases, often using CPT
members as expert witnesses on the stand. “[Dr. Walker] is
the most credible medical expert on pediatric trauma and
physical child abuse in the state,” says Drake. The CPT team
is also involved with many cases in Anne Arundel and Baltimore counties, as children critically injured there are often
flown to Hopkins for CPT evaluation.

In all, officials from these jurisdictions meet with CPT
personnel to discuss more than 500 cases annually. It is a
triage of a different kind, where diagnoses can set into motion
both the wand of caduceus and the wheels of jurisprudence.

Making those diagnoses is equal parts science and art.
Technical advancements in neuro-imaging, MRI, and CT
have brought to light many abusive injuries that were once difficult to pinpoint. “Without CT scans, something like a subdural hemotoma (essentially a bruise to the brain)—which is
one of the hallmarks of abusive head trauma or Shaken Baby
Syndrome—is almost impossible to diagnose,” says Walker.

These scans have led to new computer and biophysical
models that have experts rethinking what once were considered “pathoneumonic,” or absolute, guaranteed signs that a
child had been physically abused. “What people said 10 years
ago as being tried and true abuse is absolutely wrong,” says
another member of the CPT team, pediatrician Mitchell
Goldstein. He uses spiral femur fractures as an example.
“The thought was that you had to grab and twist the leg to get
that fracture,” says Goldstein. “In fact, it’s not an uncommon
injury in ambulatory toddlers; they put their foot in a hole,
plant and twist, and get that fracture pattern. People had
their kids removed from the home and spent time in our jail
for our naivete.”

Actually, says Goldstein, “very few injuries say, ‘this is absolute abuse.’” Like an undated black-and-white photo of
strangers plucked from a family album, images and scans often
raise as many questions as answers. With many plausible explanations for an injury, it’s the art of the interview—and the
skill of the interviewer—that often narrows the possibilities.
That’s where the work of CPT’s social workers and nurse
practitioners comes into play.

“You have to be careful not to ask leading questions,” says
social worker Kathy Kopf. “That’s very important because
otherwise [the victims] testimony won’t stand up in court.”

“The goal,” adds nurse practitioner Shawna Mudd, “is to
get an injury history from a kid. If I say, ‘Tell me what brought
you here today,’ a 7-year-old can go from there,” says Mudd.
As an example, she plays out a hypothetical dialogue involving
a belt or extension cord, which is the most common abuse object. When a child admits to a beating applied by dad with a
belt—and many kids see it as just a normal part of their upbringing—Mudd will seek specifics that hopefully match the
physical evidence. “Tell me about the belt,” she’ll say. “How
was your dad holding it? What’s the color of it? Who does it
belong to? Did anybody see you get hit with the belt? Has it
happened before? Are you scared?”

With younger children—and Kopf says it’s even possible to
get tangible leads from barely verbal toddlers—providing a
coloring book or toys is often a quick way to get them to feel comfortable enough to talk about their lives, their loves, and
their abusers, as they parse out details with little understanding of potential consequences. Older kids and teens often
have that understanding—some have been removed from
their homes before because of abuse. They sometimes lie
about their injuries at first, but generally reconsider when
shown or told about the physical evidence that doesn’t match
up with their story.

The social workers never emphasize punitive measures
that caregivers could face: The decision whether to place a
child in protective custody is made by the city Department of
Social Services/Child Protective Services social worker in the
ED, after reviewing the CPT’s evidence, interviews, and conclusions. As for arresting the abuser—and under Maryland
Law any adult who leaves a mark on a child can be arrested for
child abuse—that choice falls to the city’s detectives, again depending to a large degree on CPT’s data.

Instead, the social workers—and the whole CPT team—
focus on the child’s immediate safety. It’s the message given to
the child and the alleged abuser. “If I were a parent and being
questioned, or my child was in a separate room being questioned, I can understand being irate,” says Kopf. “I tell parents, ‘I understand you’re upset, but this isn’t personal. Child
abuse does happen, and we just want to make sure your child
is safe.’ If they can see the big spectrum, as uncomfortable, as
intrusive as it may seem at the time ... nine times out of 10 the
parents can be calmed down.

“But,” she admits, “it’s easier said than done.”

*** Back in the pediatric ED Office just off the
nursing station, nurse practitioner Joyce Ordun is studying
what amounts to the crime scene on paper. In front of her is
the special two-page CPT form assigned to document each
case. Ordun, after examining the 4-year-old and interviewing
her, has put small marks on the outline of the human body
that’s part of each form. Each mark is assigned a number, used
to cross-reference and explain each observed lesion in the “assessment” area opposite the drawn body. Each number represents a potential site of abuse.

On this form, Ordun has marked 10 such sites.

In addition to the obvious black eye—mark # 10—there
are fresh wounds at the hairline and a tiny slash through the
right eyebrow. “Red, up on her forehead, consistent with being
hit by something linear, like the side of the belt. These are
new,” she notes.

This is not conjecture, but corroboration. After the 4-year-
old admitted being coached to lie by her mother, she proceeded to tell the rest of the story, repeating it twice separately to
CPT social worker Dawn Walker (no relation to Allen Walker) and later Ordun.

“What did she hit you with?” Ordun had asked.

The little girl, coloring a small Mission to Mars comic
book, barely paused to look up.

“She hit me with a belt.”

“Did she hit you with the part that hooks together, or the
regular part?”

“The regular part.”

Several marks on the lower body confirm the girl’s comments that she’d been beaten before. Hyper-pigmented (older, still discolored) lesions on the back of her legs are loop-shaped (“from when you fold a belt over,” explains Ordun)
and their location rule out an accident or fall as the cause of the markings. “If they were on the front of her legs I wouldn’t
worry about them because the kid is [normally] moving forward. But most kids don’t get linear, hyper-pigmented lesions
between their legs.”

“So she was whacked from behind?”

“Yeah,” says Ordun, peering over the paperwork. In the
end, the form calls for her to check off one of four boxes.
These indicate that the exam reveals physical findings consistent with physical child abuse; findings consistent with neglect; findings unclear or non-specific for physical abuse or
neglect; or a history concerning for abuse but physical findings
that are non-specific (physical abuse is generally considered
an intentional act, while physical neglect—such as poorly
nourished children—includes maltreatment due to inattentiveness or ignorance).

Ordun’s choice will send a ripple through both the judicial
system and the lives of the girl, her mother, and another family member who now sits in Exam Room 3. Cradled in the
arms of the man the little girl calls her father is a 5-month-old
girl. The infant is the little girl’s sister: On her cheeks are two
quarter-sized abrasions, one under each eye. The mother says
her family doctor called the abrasions eczema. Though resting
comfortably in the man’s arms, the infant’s size and general
condition—a bit disheveled—raises the alarm of another CPT
social worker watching from the corridor.

“That baby’s not big,” she says quietly, but her worried eyes
clearly rephrase the thought.

That baby’s in trouble.

***

Even with all the technical advancements, child abuse remains a frustrating field of work. On one level, theChild Protection Team has made important inroads, especially in the coordination of
care. In addition to children who come through
the ED, the team is available to anyone who has a pediatric inpatient they suspect has been abused. These account for an estimated one-third of the team’s consults, a
service clearly appreciated by faculty and staff.
“We take pressure off the surgeons and social workers,”
says CPT social worker Sue Barker. “They can focus on the
families. We can, for lack of a better term, do the dirty work.”
In a sense, CPT’s presence allows the inpatient units to continue their normal continuity of care for the patient and the
family while CPT begins its evaluation. The trust the inpatient team has created with the family remains intact. If CPT
determines abuse has occurred, the team works with security
and the city’s Child Protective Services division to limit the
suspected abuser’s hospital access while the rest of the family and the child receive the social and medical services they need.

Still, for all the cases, the commitment, the sense that
CPT’s efforts, as nurse practitioner Shawna Mudd puts it,
“feel like the right thing,” the truth, as she says in her very next breath, is that “we don’t have data or research to show that.”

In short, while much research literature has been devoted
to the downstream effects on victims of child abuse—including increased teen pregnancy and school dropout rates—precious little is known about short-term outcomes following a
child abuse diagnosis. This is especially true when it comes to
understanding whether medical and educational interventions prevent future episodes of child abuse. While Mitchell
Goldstein is documenting whether parents who sign a nursery
commitment “not to shake my baby”’ follow through on that
pledge, such studies in aggregate are hard to come by. “In
terms of where these kids are five years later, in terms of good
solid data, we know less about the natural history of child
abuse and neglect than most other diseases, because it is such a sensitive subject,” says Walker.

Between legal juvenile privacy concerns, poor data keeping by government agencies, and general turf wars by the bureaucracies involved, it’s often hard to uncover a child’s past abuse
history, let alone mount research and prevention efforts.
While a recent law allows the city’s Child Protective Division
to disclose “active” cases, specifics often remain elusive. The
consequences of this data chasm can be devastating. Abusive
parents often hospital jump, so their child is never seen in the
same ED twice. Certain injuries that in isolation appear accidental might be judged differently if a history of repeat occurrence were available. Only it’s usually not.

Perhaps most frustrating is the realization that, while child
abuse is horrific, the abusers often act out of ignorance more
than willfulness. “For the most part, there are very few evil
people,” says Kathy Kopf, an observation consistently shared
by other CPT members. Lack of parenting tools, repeating
the discipline they themselves encountered as children...these
are often at the heart of an abuser’s actions, especially those
parents at wits’ end over their child’s behavior. Kopf recalls a
court-ordered physical abuse offenders group she facilitated.
After 16 weeks, she concluded their desires were the same as
those of most parents: To have their kids stay off drugs and do
well in school. The devil was in the details. “Part of it is changing a belief system; that if you hit your child that corrects the
behavior. A lot of research [says] it doesn’t work. It just makes
a child angry. They’re more likely to abuse a peer at school,”
says Kopf. “Also, a lot of parents are religious. They believe in
‘Spare the rod, spoil the child.’ I hear that a lot. ‘The Bible says
it’s OK.’”

For now, such educational research and interventions are beyond CPT’s scope, falling instead to
the city’s incredibly overworked Child
Protective Services division. The team
itself operates more on commitment
than cash, as Walker and Goldstein are
part-time staff and every member of
the team has other hospital and ED re-
sponsibilities.

What may improve both the research and staffing situation long term,
says Walker, is the recent decision by
the American Academy of Pediatrics to
create a board-certified child abuse
subspecialty. Such a subspecialist
“would be in the academic model, seeing patients, evaluating patients, but
also having time to pursue research
needs in the field,” says Walker.

What may be more immediately
possible is an independent one-stop
clinic. “Picture, if you will, a place
where Mitch [Goldstein] and I go to
work, along with the State’s Attorney,
some folks from Protective Services,
some Child Abuse detectives, and
that’s our office,” says Walker. “We
spend our days talking to each other
over the coffee machine, coming in
from the parking lot. That’s the kind of
service model that results in the best
deal for kids.”

In fact, such a model already exists in the Baltimore Child Abuse Center on North Charles Street. Since 2002 the center has been the clearinghouse for suspected sexual abuse cases, with detectives on-site. “This is like working in real time,” says Lt. Thomas Uzarowski, head of the Baltimore City Police Department’s Child Abuse unit. “If in the course of a [medical] inter- view sexual abuse is suspected, they just call down to the first floor, where we
are, and a detective goes up and sits in on an interview. If criminal allegations arise, we roll on it,” says Uzarowski, whose unit also works with the CPT. “The next step is where we evolve to doing physical abuse cases [in a freestanding unit]. It’s just a
matter of dollars and cents.”

That those dollars are difficult to find is a bit mystifying to
people who spend every day watching a parade of innocent
children who’ve been beaten, burned, and literally boiled for
something as simple as soiling when they’re not supposed to,
or misplacing a T-shirt. Sometimes one can hear a Sisyphean
weariness in their voices, at other times utter rage at the cases
they absolutely know are child abuse, but medically can’t
prove.

But perhaps the greatest miracle is that overriding all of
these emotions is a sense of hope for both parent and child,
that the cycle of abuse can be broken and a family can eventually be reunited. “Do I see awful things? Yes. Does it get to me
sometimes? Yes,” says Kathy Kopf, who knows that separating a child from a parent should be viewed as
a short-term option, not a long-term solution. “But I don’t look at it as doom
and gloom. I look at it as an opportunity
to get parents through this crisis situation. They made a mistake. For me it’s
about what we can do so that it doesn’t
happen again.”

*** “WHAT’S GOING ON BACK there?” demands the little girl’s mother
in the ED’s waiting room. “They’re not
telling us anything!” Social worker Dawn Walker’s face is
placid in the face of such emotion—heck,
that’s her job—but her internal calculus
is whirring, forming an equation that’s
rapidly tilting against the mother. The
more she talks with the clearly annoyed
woman, the greater the number of risk
factors for abuse she sees. She’s a young
parent. Two young children. She’s not
taking this seriously, almost as if it’s a
joke. Her story of how the injury occurred doesn’t match the facts. And she’s
just asked if the doctors found any additional marks.

“Yes, they’re old, but the doctors did
find some marks,” says Walker.

“Whaaat?” sputters the mother. “She
doesn’t get abused.”

Inside the ED office, nurse practitioner Ordun takes one last look over the
exam form, checks the box marked
“Exam reveals physical findings consistent with physical child abuse,” and offers up her informed opinion of the case.

“Mom,” she says, “is going to jail.”

A few minutes later, a new sound
comes from Exam Room 3. It is the
sound of a 4-year-old suddenly stripped
of her innocence. Sobs so grief-choked
that they barely escape her throat. Walker puts her arm around the tiny girl, pulls
her close, and attempts to explain the
impossible. The CPS social worker has
made a decision. For the time being, both sisters will be placed under the care of DSS. The little girl
won’t be going home tonight.

“We want to make sure it’s safe when you go home again,”
says Walker, offering comfort to the shattered girl. Walker can
see what’s in the girl’s tear-streaked face, the notion that
somehow she has brought this upon herself, she is at fault, she
has caused this rip in her world. “You have to remember, you
didn’t do anything wrong. You did not do anything wrong. Are you
going to remember that?” asks Walker.

Distraught, the little girl seeks relief from the only person
who can bring it. The person who created this trauma in the
first place. Her abuser.

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About Me

As a famous TV shrink once noted, the key to a full life is "A little song, a little dance, a little seltzer down your pants." I take my work, my writing, seriously. Me? Not so much. After 30 years in the journalism game, I'm using this blog to step out from behind the third-person curtain. Opinion, essay, informed reportage...I can't guarantee what you'll see from day-to-day, but I promise I'll give it an honest turn and a unique take. Let me know whatcha think.
Thanks, as always, for your time and consideration,
Mat